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The transformational nature of the aids response

The transformational nature of the aids response. Peter Piot,MD,PhD. A global view of HIV infection 33 million people [ 30–36 million ] living with HIV, 2007. 2.2. Number of people receiving ARV therapy in low- and middle-income countries, 2002—2007.

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The transformational nature of the aids response

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  1. The transformational nature of the aids response Peter Piot,MD,PhD

  2. A global view of HIV infection 33 million people [30–36 million] living with HIV, 2007 2.2

  3. Number of people receiving ARV therapy in low- and middle-income countries, 2002—2007

  4. Decline in adult mortality with introduction of ART: Botswana

  5. HIV prevalence (%) among pregnant women attending antenatal clinics in sub-Saharan Africa, 1997–2007 Southern Africa Botswana 50 Burkina Faso Lesotho 40 Mozambique 30 Namibia NOTE: Analysis restricted to consistent surveillance sites for all countries except South Africa (by province) and Swaziland (by region) Median HIV prevalence (%) 20 South Africa Ghana Swaziland 10 Zimbabwe 0 1997– 1998 1997– 1998 1997– 1998 1999– 2000 1999– 2000 1999– 2000 2001 2001 2001 2002 2002 2002 2003 2003 2003 2004 2004 2004 2005 2005 2005 2006 2006 2006 2007 2007 2007 Eastern Africa West Africa 20 20 15 15 Ethiopia 10 10 Median HIV prevalence (%) Median HIV prevalence (%) Côte d'Ivoire 5 5 Kenya Senegal 0 0 2.9 Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS.  July 2008.

  6. Number and percentage of HIV-positive pregnant women receiving antiretroviral prophylaxis, 2004–2007 40 600 000 35 500 000 30 400 000 Number of HIV-positive pregnant women receiving anti-retrovirals % of HIV-positive pregnant women receiving anti-retrovirals 25 300 000 20 15 200 000 10 100 000 5 0 0 2004 2005 2006 2007 Year Source: UNAIDS, UNICEF & WHO, 2008; data provided by countries. 4.13

  7. AIDS IS NOT OVER

  8. HIV prevalence (%) in adults (15–49) in Africa, 2007 2.8

  9. HIV infections among men having sex with men in Asia

  10. The aids response is transformational • Science and rights driven • Political approach • Focus on results for people • Prevention AND treatment • Multi-disciplinary, multi-sectoral • Community engagement • Global response

  11. Good politics, bad politics: the experience of Aids PPiot, HLarson,SRussell. Am J Publ Health, 2007;97:1934

  12. Recorded female deaths in South Africa and Brazil for ages 15-64 years Brazil, 2004. South Africa, 1997. South Africa, 2004 Source: Nathan Geffen. Statistics South Africa and Instituto Brasileiro de Geografia e Estatistica.

  13. Median percentage of population reached with HIV prevention services within the specified legal environment 100 Countries reporting having non-discrimination laws/regulations with protection for this population Countries reporting NOT having non-discrimination laws/regulations with protection for this population 80 Median percentage of population reached with HIV prevention services (UNGASS indicator 9) 60 40 20 0 Sex workers (N=42) Injecting drug users (N=17) Men having sex with men (N=28) Source: UNGASS Country Progress Reports 2008. 3.7

  14. Treatment Action Campaign (TAC), South Africa

  15. UN security Council Resolution 1308 (2000) on AIDS

  16. Total annual resources available for AIDS1986‒2007 US$ million 10 billion 10 000 8.9 billion 9000 Signing of Declaration of Commitment on HIV/AIDS,UNGASS 8000 8.3 billion 7000 6000 World Bank MAP launch 5000 4000 Gates Foundation PEPFAR 3000 UNAIDS Less than US$ 1 million 2000 1623 1000 Global Fund 292 257 212 59 0 ‘06 2007 1986 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 Notes: [1] 1986-2000 figures are for international funds only [2] Domestic funds are included from 2001 onwards [i] 1996-2005 data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006) [ii] 1986-1993 data: AIDS in the World II. Edited by Jonathan Mann and Daniel J. M. Tarantola (1996)

  17. Resources available to HIV-related programmes by source and bilateral disbursements, 2006 Total Resource availability for HIV-related programmes in 2006(US$ Billions) Bilateral disbursements to HIV-related programmes in 2006 10 9 Other DAC country members 1% (US$ Billions) EC (0.5%) Belgium 1% 8 Spain 1% UN (2%) 7 Norway 2% 6 Australia 2% GFATM (7%) Germany 2% 5 Foundations (11%) Canada 2% 4 Sweden 3% Bilaterals (33%) Netherlands 3% 3 Domestic Public and Private (46%) Ireland 3% 2 United Kingdom 9% 1 United States 71% 0 Total resources available: US$8.9 Billion Percentage out of the total bilateral disbursements Total Bilateral disbursements 2006: US$ 2.9 Billion The organizational disbursements are different than commitments or obligations, as well as different from in-country expenditures Sources: UNAIDS analysis based on OECD/DAC online database (last visited on May 6, 2008), Resource availability UNAIDS 2005, Funders Concerned About AIDS (FCAA), European HIV/AIDS Funders Group (EFG) for Philanthropic sector G

  18. Netherlands 521 Sweden 462 Ireland 408 United Kingdom 328 United States 120 France 93 Germany 60 Canada 50 Japan 24 Italy 4 0 100 200 300 400 500 600 US$ Disbursements for HIV per US$ 1 Million GDP, 2006 Sources: UNAIDS and Kaiser Family Foundation analysis, June 2007; Global Fund to Fight AIDS, Tuberculosis and Malaria online data query May 2007; International Monetary Fund, World Economic Outlook Database, April 2007. H

  19. Prices (US$/year) of first-line antiretroviral regimen in Uganda: 1998-2003

  20. Focus on results for people • Targets • Know your epidemic and the society • Monitor and evaluate • Invest in information systems

  21. Know your epidemic

  22. Number of HIV infections each year by route of transmission in Cambodia, 1988-2004 Number of new HIV infections each year by route of transmission in Cambodia, 1988-2004 ( Source: Peerapatanapokin and Brown, using Asian Epidemic Model) 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Male clients Sex workers Wife from husband Husband from wife Mother to child Source: Peerapatanapokin and Brown, using Asia Epidemic Model

  23. Impotence fears hit polio drive By Ashfaq Yusufzai BBC News, Peshawar Health officials in Pakistan say they have failed to immunise over 160,000 children against polio due to rumours the vaccine causes sexual impotence. Parents in parts of northern Pakistan told the BBC news website they feared an "American conspiracy" to cut the fertility of the next generation. At least 39 cases of polio were reported in 2006, 15 of them in the North West Frontier Province (NWFP) and the tribal areas in which only 20% of people are immunised. Worldwide 1,902 cases of polio were reported during the year, a recent WHO report said. A WHO meeting in Geneva last October heard that children paralysed by polio around the world were infected by viruses originating from Pakistan, Afghanistan, India and Nigeria. Radio rumours The main opposition to the drive in Pakistan came from local clerics who run illegal FM radio channels in many NWFP districts and the tribal areas, say officials. Amirullah Khan, a resident of NWFP's Swat district, quoted Maulana Fazlullah of a local FM channel as telling his listeners the vaccination drive was "a conspiracy of the Jews and Christians to stunt the population growth of Muslims".

  24. The PREVENTION GAPPersons at risk with access to selected prevention interventions, 2006 Source: Global HIV Prevention: the access and funding gap. June 2007

  25. Cost Effectiveness

  26. A multi-disciplinary, multi-sectoral response • Health outcomes determined by multiple factors and interventions • Particularly key besides health: law, education, work place, trade, armed forces • Need to expand resource base • First genuine business engagement in health

  27. Percentage of countries with sectors included in the national AIDS strategy and earmarked budgets Military/police Sector included Labour Health Earmarked budget present Transportation Agriculture Minerals and energy Trade and industry Tourism Public works 0 20 40 60 80 100 Percentage of countries (%), N=126 Source: UNGASS Country Progress Reports 2008. 6.5

  28. Community engagement • From planning to implementation • Makes or breaks programmes • “Aids literacy” • National Aids Councils and Global Fund Country Coordination Mechanisms • Societal sustainability and resilience

  29. TASO, Uganda

  30. A global response • Global public good and strategic issue • Role of United Nations • Global civil society and activism • International financing • Generation WE

  31. World Bank Multi-country AIDS Program (2000) • Global Fund to Fight AIDS, TB and Malaria (2002) • PEPFAR, (2003) • Unitaid (2005) • (PRODUCT) Red (2005) • Debt2Health (2007) New instruments for AIDS financing

  32. Opportunities for global health • Increased funding (ODA and research) • Collateral benefits (TB,malaria, health systems) • Culture of accountability • Tiered pricing • Engagement of non-medical sectors • Boost to research • Major interest by young people • But: how long will the momentum last?

  33. Total health ODA commitments, 2001-2006 US$ Billions

  34. Increase in TB financing and new sputum positive cases detected and treated

  35. Direct funding of health systems through Global Fund grants

  36. Conclusions • Science AND justice as basis for policy • Nothing for the people without the people • Genuine multi-disciplinarity in planning, research and implementation • Prevention AND treatment • Information for accountability and programming • Think long term and invest in capacity

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